Quality improvement in practice: improving diabetes care and patient outcomes in Aboriginal Community Controlled Health Services

Abstract

BackgroundManagement of chronic disease, including diabetes, is a central focus of most Aboriginal Community Controlled Health Services (ACCHSs) in Australia. We have previously demonstrated that diabetes monitoring and outcomes can be improved and maintained over a 10-year period at Derby Aboriginal Health Service (DAHS). While continuous quality improvement (CQI) has been shown to improve service delivery rates and clinical outcome measures, the process of interpreting audit results and developing strategies for improvement is less well described. This paper describes the evaluation of care of patients with type 2 diabetes mellitus (T2DM) and features of effective CQI in ACCHSs in the remote Kimberley region of north Western Australia.MethodsRetrospective audit of records for Aboriginal and Torres Strait Islander primary care patients aged ≥15 years with a confirmed diagnosis of T2DM at four Kimberley ACCHSs from 1 July 2011 to 30 June 2012. Interviews with health service staff and focus group discussions with patients post audit. Main outcome measures: diabetes care related activities, clinical outcome measures and factors influencing good diabetes related care and effective CQI.ResultsA total of 348 patients from the four ACCHSs were included in the study. Clinical care activities were generally high across three of the four health services (at least 71% of patients had cholesterol recorded, 89% blood pressure, 84% HbA1c). Patients from DAHS had lower median cholesterol levels (4.4 mmol/L) and the highest proportion of patients meeting clinical targets for HbA1c (31% v 16% ACCHS-3; P = 0.02). Features that facilitated good care included clearly defined staff roles for diabetes management, support and involvement of Aboriginal Health Workers, efficient recall systems, and well-coordinated allied health services. Effective CQI features included seamless and timely data collection, local ownership of the process, openness to admitting deficiencies and willingness to embrace change.ConclusionsWell-designed health care delivery and CQI systems, with a strong sense of ownership over diabetes management led to increased service delivery rates and improved clinical outcome measures in ACCHSs. Locally run CQI processes may be more responsive to individual health services and more sustainable than externally driven systems.

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“…Stoneman et al . retrospectively audited 348 Aboriginal and Torres Strait Islander patients with type 2 diabetes, finding that 26% met their target HbA1c levels of ≤ 7% . For our 47 clients with diabetes, considerably more achieved this target at the initial (n = 29 [61.7%]) and final measurement (n = 31, 66.0%]) times, most likely reflecting that our client sample did not comprise Aboriginal and Torres Strait Islanders.…”

“…The study design was based on Cusack et al . and Stoneman et al . who retrospectively audited the effect of interventions for people with type 2 diabetes.…”

“…A retrospective medical record audit was undertaken for services provided by the SRF HAT based at Sefton Park Primary Health Care Service between January 2012 and September 2015. The study design was based on Cusack et al 19 and Stoneman et al 20 who retrospectively audited the effect of interventions for people with type 2 diabetes. The study was approved as a quality assurance activity by the Royal Adelaide Hospital Research Ethics Committee.…”

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“…argue that within Indigenous health services, locally run quality improvement processes may be more responsive to individual health services and more sustainable (Stoneman et al . ). Framework implementation for those services will need to be designed and supported by them in partnership with the multiple agencies that influence their model of service delivery.…”

“…In this context, this is important both for non-government Indigenous health services, represented in Australia by a national network of Aboriginal and Torres Strait Islander community controlled health organisations, and Indigenous people at the grass roots level to work to the national agenda. Stoneman et al argue that within Indigenous health services, locally run quality improvement processes may be more responsive to individual health services and more sustainable (Stoneman et al 2014). Framework implementation for those services will need to be designed and supported by them in partnership with the multiple agencies that influence their model of service delivery.…”